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<meta name="description" content="昨天听了一天课，在昆明市延安医院。免费的。上午是孟玉坤老师讲咬合重建。下午是刘洋老师讲调颌。来了好多人，很多都认识，口腔的圈子就那么小。孟老师推荐用咬合板来通过升高咬合，获得治疗性颌位，然后在这个颌位基础上进行全口咬合重建恢复患者正常的咬合关系。咬合重建，最关键的是判断患者的口颌系统是处于生理状态下还是病理状态下。咬合重建三要素，初学者用咬合板比用暂时修复体要好。让功能尖，切端要到一个平面上，前伸">
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        <p>昨天听了一天课，在昆明市延安医院。免费的。上午是孟玉坤老师讲咬合重建。下午是刘洋老师讲调颌。<br>来了好多人，很多都认识，口腔的圈子就那么小。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/01.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/02.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/03.png"><br>孟老师推荐用咬合板来通过升高咬合，获得治疗性颌位，然后在这个颌位基础上进行全口咬合重建恢复患者正常的咬合关系。<br>咬合重建，最关键的是判断患者的口颌系统是处于生理状态下还是病理状态下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/04.png"><br>咬合重建三要素，初学者用咬合板比用暂时修复体要好。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/05.png"><br>让功能尖，切端要到一个平面上，前伸运动前牙引导，侧方形成侧导。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/06.png"><br>咬合板的咬合点前方留0.5mm，后方留2.0mm。<br>前导用两颗牙或四颗牙。三天至一周调一次，两周调第二次，一个月调第三次。不适随诊。不适的原因：咬合升高的太多，应该逐渐升高，先升2mm左右。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/07.png"><br>稳定性咬合板的主要目的是让患者适应垂直距离，三个月复查cbct，如骨皮质无问题就可以做。咬合板主要做在上颌，调颌比较方便。做在下颌则比较美观。<br>将治疗颌位转移到颌架上，要用咬合记录，不能直接用咬合板。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/08.png"><br>非正中关系，可以参考咬合板的数据。<br>在修复时，做两个导板，全牙列的，以及没有3,7的导板。<br>牙体预备时先备其余的，留那4颗牙别备，等其余牙做好暂时修复体，再用全牙列导板备剩余的四颗。<br>修复时分两侧后牙和前牙，三次修复。不要一次完成所有修复。<br>临时修复体要再次上颌架。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/09.png"><br>对于关节弹响的病例，别轻易承诺。<br>对有夜磨牙的情况，强烈建议做夜磨牙垫。<br>用面弓可以在颌架上抬高咬合，其它颌架不行。简单颌架只能固定关系，不能模拟开闭运动，半可调，可调颌架可以模拟非正中运动。<br>初学者的病例选择：髁突在关节窝内的，基本无骨皮质吸收的。<br>相对于稳定性咬合板，定位咬合板是主动介入，预设最终位置。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/10.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/11.png"><br>最好的颌架，最好的咬合记录系统，是患者自己的口颌系统。<br><strong>（总结：咬合重建，最重要的是判断患者的口颌系统是生理性的还是病理性的，然后用咬合板恢复正常协调的口颌系统关系，然后在这个关系的基础上进行修复。对于我来说，遇到需要咬合重建的病例肯定是选择转诊的，面弓、颌架我都没正儿八经用过。咬合重建别轻易上手，很容易收不了场的。就当科普吧。）</strong><br>下午是刘洋老师的调颌的课程。我在15年去广州进修的前一天，在昆明听了刘洋老师的调颌课程，感觉收获蛮大。这次又来回炉了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/12.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/13.png"><br>刘老师说讲的东西都在这两本书里，于是没怎么拍照了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/14.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/15.png"><br>临床上调颌时视觉上的均匀接触可能是假象，有咬合高点时下颌可能移位形成假咬合接触。解决方法是进行有创操作前记录咬合状态。调颌的第一步就是进行术前咬合记录。蓝色咬合纸调功能运动，红色咬合纸调正中记录。术前术后咬合往往被改变。先做非正中咬合，再做正中咬合。红蓝相间的点就是正中咬合的点，如果红蓝没有重合说明下颌咬偏了。先用100微米的蓝色咬合纸调非正中颌，再用40微米红色咬合纸调正中咬合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/16.png"><br>调颌的步骤如上。<br>体位：坐位和平躺都要调。<br>正中位：咬合纸从厚到薄咬，调到有均匀的咬合接触。然后用术前记录对比。功能尖内斜面要有咬合。正中咬合时后牙均匀接触，前牙轻接触（40微米有接触，8微米没接触，留下20微米的间隙）<br>非正中咬合<br>理想状态下：<br>前伸前牙有接触，其余脱离。侧方工作侧尖牙接触，其余牙脱离。<br>正中咬合后牙接触，前牙脱离。<br>有条件的情况下尽量建立尖牙保护颌，不要建立组牙保护颌。（如果患者本身就是组牙颌，也别轻易去磨）<br>多颗前牙调不好，在口内无法控制方向。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/17.png"><br>两个的咬合印迹是差不多的，但是牙齿运动轨迹差别很大。<br>因此出现各种问题<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0146-thkc/18.png"><br>粘冠后，让患者自由磨，看有无牙合干扰。次日必须复诊。<br>小下巴容易后牙磨耗，常规拍关节片，关节常有问题。(50%)<br>大下巴，前牙容易磨耗，易关节弹响。(10%)<br>正常下巴出问题较少。(40%)<br>遇到风险病例，完善记录，完善告知，及时转诊。<br>咬合板的风险：戴用数月后下颌后旋退缩、上颌架时没有尖窝锁结的问题。<br><strong>（总结：调颌前要做的一件事：记录患者的咬合。我从来不做的，以后要注意了。调颌时用两种颜色的咬合纸，蓝色调非正中，红色调正中。我搞到刘老师《调颌》那本书了，接下来看看吧。）</strong></p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“好看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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